What's your alternative to socialized med?

[SoCuteMD]

What's everyone's thoughts on what Massachusetts has done?

It's certainly not the end-all, be-all, since much needs to be don in regards to tort reform and defensive medicine, but it does appear to be a reasonable compromise at this juncture.

Except that you can't even GET a PCP in MA anymore. They're all full!

There is also lots of abuse by folks living in neighboring states.

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[RxnMan]

What's everyone's thoughts on what Massachusetts has done?

It's certainly not the end-all, be-all, since much needs to be don in regards to tort reform and defensive medicine, but it does appear to be a reasonable compromise at this juncture.

Except for the fact that it is not sustainable. The state had many thousands more enroll than they expected. And this is in one of the richer (per capita) states in the union.

Medicare administration runs around 5.2%. Private health insurance companies run around 17% (including profits)...

Those numbers are frequently thrown out, but they don't account for Congress, which is essentially the administration for Medicare.

 

[GoodmanBrown]

Those numbers are frequently thrown out, but they don't account for Congress, which is essentially the administration for Medicare.

Did you follow my link and read a bit from the Executive Summary? They specifically mention that in this analysis they do the best they can to account for all the "hidden costs" of Medicare. So, I think that that is included as best as people know how. I mean, if you consider the small amount of time that Congress spends on Medicare related bills (and how much we're paying them per year) vs. the total amounts that Medicare goes through, I doubt it adds that much to the total administrative costs.

So, I don't necessarily think your point counts too much against the numbers.

 

[GoodmanBrown]

There is also lots of abuse by folks living in neighboring states.

Arguably, though, this wouldn't be the case if the entire US had the same program. It's not like Canadians are going to come down to use our PCPs...

 

[EM2BE]

Arguably, though, this wouldn't be the case if the entire US had the same program. It's not like Canadians are going to come down to use our PCPs...

But this is the same problem Hawaii had with it's free child insurance Keiki Care. They expected a certain amount of children, and much more were enrolled even though they were previously insured by other plans. People found their kids would get this free insurance, so they wouldn't pay for it anymore. And if you weren't aware, this is the program SCHIP was based off, therefore, it may run into the same problems. (Keiki Care was cancelled soon after it came into effect due to lack of funding due to increased enrollment from what was proposed.)

 

[It'sElectric]

But this is the same problem Hawaii had with it's free child insurance Keiki Care. They expected a certain amount of children, and much more were enrolled even though they were previously insured by other plans. People found their kids would get this free insurance, so they wouldn't pay for it anymore. And if you weren't aware, this is the program SCHIP was based off, therefore, it may run into the same problems. (Keiki Care was cancelled soon after it came into effect due to lack of funding due to increased enrollment from what was proposed.)

To be fair, the Massachusetts plan is in no way free. And according to some of the reading I found online, while the number of people that enrolled was greater than expected, the cost per person actually came under budget.

 

[GoodmanBrown]

But this is the same problem Hawaii had with it's free child insurance Keiki Care. They expected a certain amount of children, and much more were enrolled even though they were previously insured by other plans. People found their kids would get this free insurance, so they wouldn't pay for it anymore. And if you weren't aware, this is the program SCHIP was based off, therefore, it may run into the same problems. (Keiki Care was cancelled soon after it came into effect due to lack of funding due to increased enrollment from what was proposed.)

I feel like this is a problem with Keiki Care, not a problem, overall, with having some form of government health insurance. I mean, who isn't going to take the free option when presented with it? I mean, if someone offered me free housing or a free car to use, if it was close to as decent as my present housing or car, I'd take it.

As for SCHIP, it's been around since 1997, and I have not heard reports of this problem you proprose may happen. The nice thing about SCHIP is that within certain guidelines, states have significant options as to how it's distrubuted and who's eligible. Thus, most states have an income limit of xxx% above the poverty line. This prevents people who are well off enough to easily buy their kid's insurance from just jumping on the SCHIP funds.

 

[EM2BE]

I feel like this is a problem with Keiki Care, not a problem, overall, with having some form of government health insurance. I mean, who isn't going to take the free option when presented with it? I mean, if someone offered me free housing or a free car to use, if it was close to as decent as my present housing or car, I'd take it.

As for SCHIP, it's been around since 1997, and I have not heard reports of this problem you proprose may happen. The nice thing about SCHIP is that within certain guidelines, states have significant options as to how it's distrubuted and who's eligible. Thus, most states have an income limit of xxx% above the poverty line. This prevents people who are well off enough to easily buy their kid's insurance from just jumping on the SCHIP funds.

That's the thing, they did that income limit in Hawaii too. But there were people within that income that already had insurance that got switched to the free insurance when it came out. They knew some would, but they weren't expecting as many as did do it. I want to hear from someone in Hawaii that dealt with it so we don't have to rely on the news sources for the info. Maybe then we could get a better idea of what happened.

I remember hearing something about SCHIP running into some funding difficulties a year or two ago, but I don't remember much about it.

 

[leviathan]

We've seen just how well government "fiscal austerity" has worked in the last 8 years. We've seen an even more impressive display of this "austerity" in the last 3 months as TRILLIONS have literally been flushed down a giant toilet of public waste and excess. If they managed the healthcare industry only half as badly as everything else it would be a great achievement for our politicians.

I agree with you about how badly government can F(#*@ things up, but if you just look at how they deal with health care spending, all the western governments do a much better job distributing health care dollars than US insurance companies.

 

[GeneralVeers]

I agree with you about how badly government can F(#*@ things up, but if you just look at how they deal with health care spending, all the western governments do a much better job distributing health care dollars than US insurance companies.

That is because they use several tools to make healthcare spending sustainable:

1. Rationing
2. Tort Reform
3. Unavailability of state of the art procedures/tests
4. Higher taxes

With the exception of #4, I don't think we will have any of the others. Our government has decided to pay for everything for everyone, but refuses to make any of the hard choices in terms of cost cutting, tort reform, or punishing people who abuse the system.

 

[GeneralVeers]

An article in Today's Toronto Star (a left-leaning newspaper) reported that by 2011 Canadian spending on healthcare will comprise more than 50% of the the total expenditures by the government of Canada!

http://www.thestar.com/comment/article/612824

I think this demonstrates that even in a tightly regulated and rationed system the government has a hard time constraining costs and keeping them sustainable.

 

[Perrotfish]

I'm a fan of a simple, congressional mandate that every state must see to it that every adult has the equivalent of major medica insurance, and that every child has the equivalent of full health care. No further guidance, and the responsibility for implementing it rests 100% on the states. Each state gets to choose: centralized government health care, government health insurance, mandate that everyone needs to buy their own insurance, or whatever. The taxation for the plan would also be 100% at the state level. I think this would be the best chance of people getting what they actually want.

 

[GeneralVeers]

I'm surprised that there are no comments/defense of the numbers from Canada.

Interesting....

 

[EM2BE]

I'm surprised that there are no comments/defense of the numbers from Canada.

Interesting....

Thanks for carrying the thread. Everything you have said I agree with.

 

[leviathan]

An article in Today's Toronto Star (a left-leaning newspaper) reported that by 2011 Canadian spending on healthcare will comprise more than 50% of the the total expenditures by the government of Canada!

http://www.thestar.com/comment/article/612824

I think this demonstrates that even in a tightly regulated and rationed system the government has a hard time constraining costs and keeping them sustainable.

The costs of health care are also rising in the US, and at an even higher rate. The difference is that you are paying way more for it through your private insurance due to inefficiency/wasting and high overhead costs.

http://www.cmaj.ca/cgi/rapidpdf/cmaj.081177v1

Good article reviewing the two systems. Citation of data showing much higher mortality rates from preventable disease in the US, in addition to the standard markers like life expectancy. I found it interesting to see there are actually *more* hospital beds and nurses per capita in Canada, more doctor visits per person, but on the flipside, the US has *5* times as many MRI units.

 

[GeneralVeers]

The costs of health care are also rising in the US, and at an even higher rate. The difference is that you are paying way more for it through your private insurance due to inefficiency/wasting and high overhead costs.

True, due to the more MRI machines, more advanced treatments, and more prescription drugs in this country.

My question was concerning the sustainability of even the Canadian system. If you have a system whereby MORE THAN HALF of all your expenditures are on healthcare, it will lead to inevitable collapse of the system. In the U.S. we'd simply be replacing insane unsustainable expenditures using one system for insane, unsustainable expenditures in another system.

I still say our best bet is reforming our current semi-free market system and rationing care.

 

[RxnMan]

...Good article reviewing the two systems. Citation of data showing much higher mortality rates from preventable disease in the US, in addition to the standard markers like life expectancy...

We are also a sicker country - more obesity, smoking, violence than Canadia.

 

[GeneralVeers]

We are also a sicker country - more obesity, smoking, violence than Canadia.

Exactly right. It's near impossible to compare expenditures and outcomes between countries with different demographics and disease processes. Perhaps the only countries suitable for comparison would be the Scandinavian countries with each other as their populations are relatively homogenous with similar risk factors and health risks.

There's one simple thing we need to do in this country to bring healthcare costs under control. We as physicians are not good at saying "no" to patients. We need to learn to exercise this word more frequently and appropriately. If we don't do it, then Medicare/CMS will say no for us.

 

[xaelia]

It is also much easier for a country like Canada to have its budget turn half into healthcare; they don't have nearly the proportion dedicated to defense the U.S. does.

 

[GeneralVeers]

It is also much easier for a country like Canada to have its budget turn half into healthcare; they don't have nearly the proportion dedicated to defense the U.S. does.

They don't have to because we do. The United States is essentially paying for military protection for Canada, and Europe.

 

[RxnMan]

Exactly right. It's near impossible to compare expenditures and outcomes between countries with different demographics and disease processes...

Another point - All of the foreign-trained fellows I've met came here because of the above factors, but also because we'll do more for these sick patients.

Most foreign neonatologists are not going to try to save a 23-weeker.

 

[GeneralVeers]

Another point - All of the foreign-trained fellows I've met came here because of the above factors, but also because we'll do more for these sick patients.

Most foreign neonatologists are not going to try to save a 23-weeker.

I don't believe we should be saving a 23-weeker, but that's beside the point.

Many Canadian physicians escape Canada to practice in the U.S, while few U.S. physicians go to Canada.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839794

Approximately 1 in 9 Canadian-educated physicians migrates to the United States. If socialist medicine is the "utopia" so many on here proclaim it to be, then why is this happening?

 

[GoodmanBrown]

I'm surprised that there are no comments/defense of the numbers from Canada.

Interesting....

Don't read into it too much; it's the end of the school year. Us naive, "change the world" pre-meds are all studying for finals.

Anyway, I'll throw a few counter-points out.

An article in Today's Toronto Star (a left-leaning newspaper) reported that by 2011 Canadian spending on healthcare will comprise more than 50% of the the total expenditures by the government of Canada!

I think this demonstrates that even in a tightly regulated and rationed system the government has a hard time constraining costs and keeping them sustainable.

No argument here. I don't think any country has a grip on its healthcare spending. Everywhere from Canada to Britain to Germany is seeing their healthcare costs rise quickly.

The U.S. still spends more per capita on heathcare. We're up to around 15% versus Canada's 10%. So, yes, the Canadian gov. is spending more percentage-wise, but we're still spending more after factoring in all the private health insurance, out-of-pocket, etc.

True, due to the more MRI machines, more advanced treatments, and more prescription drugs in this country.

My question was concerning the sustainability of even the Canadian system. If you have a system whereby MORE THAN HALF of all your expenditures are on healthcare, it will lead to inevitable collapse of the system. In the U.S. we'd simply be replacing insane unsustainable expenditures using one system for insane, unsustainable expenditures in another system.

I still say our best bet is reforming our current semi-free market system and rationing care.

GV, I have a very hard time following your argument. You say that Canada rations treatment, and by the way you phrase it, it's clearly a bad thing. But that's half of your suggestion for how to control costs in America, too. I'm confused as to why you dislike the Canadian system if it's doing what you suggest should be done?

Also, your quote on MRI machines, advanced treatments, etc. is kinda interesting because Levanthian gives a link to an article that shows that life expectancy is greater in Canada and that they beat us on a variety of health indicators. So, combining the two points essensially boils down to, we spend more on fancy medical technology and treatments that give no discernable benefit to the recipient.

They don't have to because we do. The United States is essentially paying for military protection for Canada, and Europe.

This has been the U.S.'s choice for decades. Trying to put fault on Canada for having different priorities has no merit in the argument.

Approximately 1 in 9 Canadian-educated physicians migrates to the United States. If socialist medicine is the "utopia" so many on here proclaim it to be, then why is this happening?

Again, I don't feel like this is valid argument. Canadian docs come here to get paid more. Simple as that.


I think our differences stem from a simple conception about who's insured vs. uninsured in the U.S. I happen to believe that most of the uninsured are legitimately hard-working folks who are in jobs that don't offer insurance and that don't pay enough to buy insurance. I think they're putting in their 40+ hr/wk. But they work in service jobs or low-skill jobs that don't pay much. This Kaiser study bears some of this out:

http://www.kff.org/uninsured/upload/7613.pdf

It basically says that many of the uninsured are earning above 200% of the poverty line ($11,201 for single person under 65; $21,834 for a family of four). They can't buy a decent healthcare plan because they're searching on the individual market.

On the other hand, I think you and maybe EM2BE feel like most people who don't have insurance aren't really trying or are just interested in gaming the system. So, by creating some sort of subsidized healthcare system, we're just rewarding lazy behavior. Just my 2 cents. Correct me if I'm wrong.

One final question. When exactly should doctors be saying "no" to patients? You mention the MRI machines and advanced treatments, but should we be saying "no" to patients who request the latest cancer treatment in an last ditch effort to stop the disease? When is a cost-savings "no" appropriate vs. when not?

 

[RustedFox]

Wow. I've been following this discussion for awhile now. Not to sound like a giant nerd, but is anyone else as enthralled as I am with all these killer arguments? Keep it up.

 

[RxnMan]

...So, combining the two points essensially boils down to, we spend more on fancy medical technology and treatments that give no discernable benefit to the recipient...

No, when you put your two arguements together, you get a system that is burdened with the sickest population and the desire to have everything possible thrown at them.

We've known that preventative medicine (stoping smoking, eating less, exercise more, better nutrition) halts/slows down disease for at least five decades. America hasn't changed. Because we have a system that divorces payers and recipients of care (a fundamentally unstable condition), we've had increased costs through increased utilization and increased innovation. You combine poor habits with technologically advanced, no-cost-at-point-of-care medicine, and you get...US.

...One final question. When exactly should doctors be saying "no" to patients?...

When test, treatment, or intervention is not clinically indicated.

 

[GeneralVeers]

Don't read into it too much; it's the end of the school year. Us naive, "change the world" pre-meds are all studying for finals.

Eventually when you actually make money you too will join the Dark Side of Medicine.......

The U.S. still spends more per capita on heathcare. We're up to around 15% versus Canada's 10%. So, yes, the Canadian gov. is spending more percentage-wise, but we're still spending more after factoring in all the private health insurance, out-of-pocket, etc.

True, but a large portion of our spending is in the private sector. Barack Obama is looking to simply "take over" all of that spending and have it come from the government. That situation would bankrupt (more) the government within a few months

GV, I have a very hard time following your argument. You say that Canada rations treatment, and by the way you phrase it, it's clearly a bad thing. But that's half of your suggestion for how to control costs in America, too. I'm confused as to why you dislike the Canadian system if it's doing what you suggest should be done?

Rationing is going to be a necessary evil regardless of what system we're in. We can't continue to spend millions of dollar on futile treatments for the elderly. I don't like the Canadian system of government-enforced rationing, rather I think doctors need to rethink how they deal with end-of-life issues. 90% of the healthcare resources used by an individual come during the last few weeks or months of their lives. Anyone who's been in a "state-of-the-art" American ICU setting knows that many of these treatments are wasteful and give the patient no benefit. That's why we need to say "no" to patients who request heroic measures on terminally ill patients.

Also, your quote on MRI machines, advanced treatments, etc. is kinda interesting because Levanthian gives a link to an article that shows that life expectancy is greater in Canada and that they beat us on a variety of health indicators. So, combining the two points essensially boils down to, we spend more on fancy medical technology and treatments that give no discernable benefit to the recipient.

As has already been stated the United States is far sicker as a population. We have more smokers, more fat people, more sedentary lives, than the average Canadian. Therefore it's difficult to point to data like life expectancy as a measure of quality of healthcare. Our sicker population also requires a higher level of spending on average than in Canada.

Again, I don't feel like this is valid argument. Canadian docs come here to get paid more. Simple as that.

Interesting that you admit that. The studies and data quoted by Leviathan and others refuse to acknowledge that the pay rate is significantly less in Canada.

I think our differences stem from a simple conception about who's insured vs. uninsured in the U.S. I happen to believe that most of the uninsured are legitimately hard-working folks who are in jobs that don't offer insurance and that don't pay enough to buy insurance. I think they're putting in their 40+ hr/wk. But they work in service jobs or low-skill jobs that don't pay much. This Kaiser study bears some of this out:

You can believe that all you want. The vast majority of uninsured I see are illegal aliens, smokers, drinkers, or cocaine users. It's the rare honest, unfortunate, hard-working uninsured person that I see these days.

On the other hand, I think you and maybe EM2BE feel like most people who don't have insurance aren't really trying or are just interested in gaming the system. So, by creating some sort of subsidized healthcare system, we're just rewarding lazy behavior. Just my 2 cents. Correct me if I'm wrong.

You are correct. The nature of most entitlement programs is that they set up free services and income for the "poor" while at the same time do not require people to get a job, not smoke, not do drugs, or to even take care of their health. They essentially reward people for doing nothing.

One final question. When exactly should doctors be saying "no" to patients? You mention the MRI machines and advanced treatments, but should we be saying "no" to patients who request the latest cancer treatment in an last ditch effort to stop the disease? When is a cost-savings "no" appropriate vs. when not?

Some examples:

- 96 year old from nursing home who is demented and "full code" presents in cardiac arrest.
- 80 year old with prostate cancer requesting radiation and surgery
- 75 year old bed-bound demented patient who "fell" and broke a hip and needs surgery to correct it.
- Heroic measures to resuscitate infants < 27 weeks EGA.
- Octomom
-40 year old obese, smoker, who won't take his insulin for diabetes presenting for chest pain for the 4th time and wants admission for cardiac workup.

We can also cut costs by asking for money up front to see patients with non-emergent complaints. You have a tooth pain? Great, your vitals are normal, and you have no swelling in your face. That'll be $50 to be seen.

 

[GeneralVeers]

g, eating less, exercise more, better nutrition) halts/slows down disease for at least five decades. America hasn't changed. Because we have a system that divorces payers and recipients of care (a fundamentally unstable condition), we've had increased costs through increased utilization and increased innovation. You combine poor habits with technologically advanced, no-cost-at-point-of-care medicine, and you get...US.

I agree with you there. The nature of insurance needs to be changed in this country. People should be financially responsible for their routine day-to-day health and medications. I know plenty of people who will pay a mechanic $100 to have their car fixed, but refuse to pay $75 for a routine office visit.

Medical insurance should be like car insurance. It should be there only for catastrophic damage to protect you from financial ruin.

Under the new system I would require all doctor's offices and hospitals to post the costs up front before the patient is seen.

 

[GoodmanBrown]

Eventually when you actually make money you too will join the Dark Side of Medicine.......

Don't assume too much. I'm non-trad and have already earned more in one year than residents do. However, I cede that I haven't ever worked in medicine.

True, but a large portion of our spending is in the private sector. Barack Obama is looking to simply "take over" all of that spending and have it come from the government. That situation would bankrupt (more) the government within a few months.

Totally agree that just taking on all healthcare spending would bankrupt the U.S. in a short time. Unless you raised taxes and alleviated the burden of private sector healthcare spending.

Rationing is going to be a necessary evil regardless of what system we're in. We can't continue to spend millions of dollar on futile treatments for the elderly. I don't like the Canadian system of government-enforced rationing, rather I think doctors need to rethink how they deal with end-of-life issues. 90% of the healthcare resources used by an individual come during the last few weeks or months of their lives. Anyone who's been in a "state-of-the-art" American ICU setting knows that many of these treatments are wasteful and give the patient no benefit. That's why we need to say "no" to patients who request heroic measures on terminally ill patients.

I think we agree on this point. So, providing someone has private insurance (and is relatively young and healthy), do you see there ever being a time to refuse treatment? E.g. saying "no" to a CAT scan after a minor head injury, or something like that?

As has already been stated the United States is far sicker as a population. We have more smokers, more fat people, more sedentary lives, than the average Canadian. Therefore it's difficult to point to data like life expectancy as a measure of quality of healthcare. Our sicker population also requires a higher level of spending on average than in Canada.

Interesting that you admit that. The studies and data quoted by Leviathan and others refuse to acknowledge that the pay rate is significantly less in Canada.

Frankly don't have much to say to this. Point 1 is pretty spot on with what I've found, so I won't argue with you there. As to point 2, I would think it naive to say this isn't true. The consequences for doctors and patients is what's more interesting for me. If the U.S. went Canada, would our doctors go somewhere else to practice? I don't know where else they would as we currently pay our doctors the highest salaries.

You can believe that all you want. The vast majority of uninsured I see are illegal aliens, smokers, drinkers, or cocaine users. It's the rare honest, unfortunate, hard-working uninsured person that I see these days.

If you want to believe your biased, ancedotal evidence over my large, statistically rigorous survey, there ain't much I can do about it.

You are correct. The nature of most entitlement programs is that they set up free services and income for the "poor" while at the same time do not require people to get a job, not smoke, not do drugs, or to even take care of their health. They essentially reward people for doing nothing.

Again, I think we have to agree to disagree as we won't come to terms on what constitutes proof of our beliefs.

I will simply say that I think getting private health insurance as an individual is a bull**** process where a lot of moderately-ill folks get totally hung out to dry.

Some examples:

- 96 year old from nursing home who is demented and "full code" presents in cardiac arrest.
- 80 year old with prostate cancer requesting radiation and surgery
- 75 year old bed-bound demented patient who "fell" and broke a hip and needs surgery to correct it.
- Heroic measures to resuscitate infants < 27 weeks EGA.
- Octomom
-40 year old obese, smoker, who won't take his insulin for diabetes presenting for chest pain for the 4th time and wants admission for cardiac workup.

We can also cut costs by asking for money up front to see patients with non-emergent complaints. You have a tooth pain? Great, your vitals are normal, and you have no swelling in your face. That'll be $50 to be seen.

I think all these make sense. Wouldn't argue with a word of it.

 

[GoodmanBrown]

I agree with you there. The nature of insurance needs to be changed in this country. People should be financially responsible for their routine day-to-day health and medications. I know plenty of people who will pay a mechanic $100 to have their car fixed, but refuse to pay $75 for a routine office visit.

Medical insurance should be like car insurance. It should be there only for catastrophic damage to protect you from financial ruin.

Under the new system I would require all doctor's offices and hospitals to post the costs up front before the patient is seen.

I agree with you here. But in my opinion, we have to have some major reforms for this to be available. Right now, a moderately sick person (someone with a chronic disease for instance) can't even get catastrophe insurance because it's priced out of their range or denied outright. In remission? Have fun finding trying to find an insurance policy. Other than passing some law stating that insurance companies can't reject policies, change prices, or exclude pre-existing conditions, why would a company ever take these people on?

 

[RustedFox]

- While I'd also like to believe that the majority of uninsured Americans are honest, hardworking, salt-of-the-earth folk that are just priced-out by unrealistically high insurance premiums..... I have to agree with Gen. Veers in that the majority of the uninsured *THAT WE SEE IN THE EMERGENCY DEPT* (different than the subset of just 'the plain ol' uninsured, mind you) are the people who either 1) don't care to look after their own health because they know that big brother will pick up the tab, thus there is no incentive for them to change their ways, 2) are the drug-seekers, the hungry homeless, or people who are out to abuse the system for whatever sort of secondary gain they derive from a visit to the ED, or 3) are in for a bull$hit complaint of "left toe pain x6 years" or "pregnancy test" because they can't/won't pony up the money to be seen by the appropriate primary who would be better equipped and educated to handle their complaint. People abuse the system, and if that stopped (i.e. - upfront pricing), then we wouldn't have to cope with that sort of nonsense.

- Example: During one of my fourth year clerkships, I saw the same patient three times in the ED for a complaint of "toothache". Vitals fine, no swelling/infection, but had a broken pre-molar which was obviously sensitive to every modality of stimuli (and that will happen when your diet consists of every sugary food on the planet and you admit to not ever brushing your teeth). Each time, I gave her a local anesthetic, two or three percocets, and AN APPOINTMENT FOR THE DENTAL CLINIC. Lo and behold, she would never follow-up at the dental clinic, but faithfully showed up when she was out of pain meds. When asked why she didn't make her appointments, her reply was an astonishing - "I don't know". She got her temporary pain relief, but had no incentive to fix the underlying problem, seeing as how everything to her "was free".

Give a man a fish, and he eats for a day. Teach a man to fish, and he eats for a lifetime.

 

[GeneralVeers]

Don't assume too much. I'm non-trad and have already earned more in one year than residents do. However, I cede that I haven't ever worked in medicine.

Totally agree that just taking on all healthcare spending would bankrupt the U.S. in a short time. Unless you raised taxes and alleviated the burden of private sector healthcare spending.

THAT is the six ton elephant in the room that no one down here will speak of. Obama is going to have raise taxes on every single taxpayer in order to pay for his programs. Sure you can get some of it out of the rich, but there's a certain point where you can't get any more money out of them.

I think we agree on this point. So, providing someone has private insurance (and is relatively young and healthy), do you see there ever being a time to refuse treatment? E.g. saying "no" to a CAT scan after a minor head injury, or something like that?

I practice what I preach. I don't order expensive CTs or MRIs on patients who don't need them. Likewise I don't do the cardiac workup on the average 20-year old anxious female with pleuritic chest pain (see 2-3 of these daily!). How many of you guys order labs for the epigastric pain with vomiting and diarrhea in a young person? Not me.

The other day one of the local nursing homes was dumping patients on us, and we literally got four 80+ year old demented people sent from the same nursing home for "syncope". Two of these people had reasonable families. After some basic lab tests I sat down with the families and explained that it could be a stroke or heart attack, however I didn't feel that much could be done for them in hospital. The families then thanked me, and requested that their relatives be sent back to the nursing home instead of being admitted. THIS is what we need to start doing. We need to represent the best interest of our patients, and sending these people home without a $1 million hospital stay was the best thing for everyone.

Frankly don't have much to say to this. Point 1 is pretty spot on with what I've found, so I won't argue with you there. As to point 2, I would think it naive to say this isn't true. The consequences for doctors and patients is what's more interesting for me. If the U.S. went Canada, would our doctors go somewhere else to practice? I don't know where else they would as we currently pay our doctors the highest salaries.

My plan is New Zealand/Australia. The weather is better than Canada.

If you want to believe your biased, ancedotal evidence over my large, statistically rigorous survey, there ain't much I can do about it.

Talk to most of the attendings who've been practicing a while (not me) and see if they agree with me on this point or not.

 

[GeneralVeers]

- Example: During one of my fourth year clerkships, I saw the same patient three times in the ED for a complaint of "toothache". Vitals fine, no swelling/infection, but had a broken pre-molar which was obviously sensitive to every modality of stimuli (and that will happen when your diet consists of every sugary food on the planet and you admit to not ever brushing your teeth). Each time, I gave her a local anesthetic, two or three percocets, and AN APPOINTMENT FOR THE DENTAL CLINIC. Lo and behold, she would never follow-up at the dental clinic, but faithfully showed up when she was out of pain meds. When asked why she didn't make her appointments, her reply was an astonishing - "I don't know". She got her temporary pain relief, but had no incentive to fix the underlying problem, seeing as how everything to her "was free".
.

This is why we need to just say NO! Whenever I see a tooth pain I look to see if they've been to the ER within the last 6 months for tooth pain. If they have, they get Penicillin, non-narcotic pain medicine and a referral to a dental clinic. Perhaps the tooth pain that doesn't get narcotics will be a big enough negative reinforcement to make them seek dental care.....nahh, they will just go to another hospital where some other sucker physician will write them for percs.

 

[GoodmanBrown]

Talk to most of the attendings who've been practicing a while (not me) and see if they agree with me on this point or not.

Fair enough. I will be so bold as to say, I think we've mostly come to some accord on most of our issues. I think we just have some underlying beliefs that cause us to see the uninsured in different lights.

This has been fun. Many other threads (esp. in anesthesia) become so vitriolic so fast that it's hard to have a good debate. This was refreshing. My faith in man(and woman)-kind has been restored.

 

[xaelia]

THAT is the six ton elephant in the room that no one down here will speak of. Obama is going to have raise taxes on every single taxpayer in order to pay for his programs. Sure you can get some of it out of the rich, but there's a certain point where you can't get any more money out of them.

Insured Americans and employers already pay monthly premiums for the privilege of (getting our claims denied) healthcare. If healthcare were consolidated as a single government payor, yes, it would then be a "tax hike", but we essentially are already paying that same monthly tax to private payors.

The ugly word for decreasing healthcare costs that I'm sure would be thrown around in any debate is "rationing", but that's going to be part of the reality of medicine in the future. If you're paying for your care with public monies, the monies need to have a justified ROI. The British health system (and in no way am I condemning or endorsing them) make available care for individuals on a sort of "productive life-years expected" scale. Not just applying evidence-based medicine throughout hospitals in the sense of "does goal-directed sepsis work" but, as GeneralVeers referred to, a certain subset of end-stage leukemia patients don't need to go down the goal-directed pathway, have continuous SVO2 monitoring, and tie up a MICU bed for a week while the family finally comes to grips with his "sudden" deterioration.

Re-establishment of outpatient primary care as the safety net would be lovely. Can you imagine an FP in this day and age seeing abdominal pain in the AM, and, rather than punt to the ED, telling them to come back in the PM for another exam, and then the next AM for another exam?

And, really, private health insurance whose CEOs get multimillion dollar bonuses based on the profits they derive by reducing payments to doctors and by denying claims by subscribers? I'm not that's an ethical business model.

Heck, I think half of our non-acute patients would stop coming in if all we did was charge $1 for parking.

 

[EM2BE]

I think our differences stem from a simple conception about who's insured vs. uninsured in the U.S. I happen to believe that most of the uninsured are legitimately hard-working folks who are in jobs that don't offer insurance and that don't pay enough to buy insurance. I think they're putting in their 40+ hr/wk. But they work in service jobs or low-skill jobs that don't pay much. This Kaiser study bears some of this out:
You can believe that all you want. The vast majority of uninsured I see are illegal aliens, smokers, drinkers, or cocaine users. It's the rare honest, unfortunate, hard-working uninsured person that I see these days.

On the other hand, I think you and maybe EM2BE feel like most people who don't have insurance aren't really trying or are just interested in gaming the system. So, by creating some sort of subsidized healthcare system, we're just rewarding lazy behavior. Just my 2 cents. Correct me if I'm wrong.



You are correct. The nature of most entitlement programs is that they set up free services and income for the "poor" while at the same time do not require people to get a job, not smoke, not do drugs, or to even take care of their health. They essentially reward people for doing nothing.

The part where you believe most uninsured people are hard-working is where I have a problem. I have seen much fewer patients who are hard working and uninsured than non-working and uninsured. Also have had several brag they were on disability so they don't have to pay for anything (in their terms). Maybe it's the patient population we are exposed to in teaching hospitals that causes us to see this mix and not the mix you are referring to. I would say easily a 10:1 ratio of not working to working and uninsured. Underinsured is another topic, but you were referring to uninsured.

 

[GoodmanBrown]

The part where you believe most uninsured people are hard-working is where I have a problem. I have seen much fewer patients who are hard working and uninsured than non-working and uninsured. Also have had several brag they were on disability so they don't have to pay for anything (in their terms). Maybe it's the patient population we are exposed to in teaching hospitals that causes us to see this mix and not the mix you are referring to. I would say easily a 10:1 ratio of not working to working and uninsured. Underinsured is another topic, but you were referring to uninsured.

I have no doubt that you and GV both see many uninsured people with no inclination to work and every desire to leech off the system. I'm not arguing that fact at all.

But in statistics, that's called selection bias. You and GV take what you see and extrapolate to all uninsured people. What you don't consider is that your sample is not representative of all the uninsured. To get a true sample, it has to be a random selection of uninsured people.

And large surveys demonstrate that the majority of uninsured do in fact have jobs that earn them enough to put them above the poverty line but too little to buy health insurance (if they aren't perfect health and always have been).

So, you can tell me you see 8,000 uninsured people per day and they all come in for a Percocet refill, but I still won't use that experience to define the characteristics of the majority of uninsured people.

If you have a study titled "Most Uninsured are Lazy Bastards" and it took a random sample of a couple thousand uninsured people and found that most of them just wanted to watch TV all day and eat Vicodin, then I will accept that as evidence of your beliefs. But that survey will be hard to find (because the title is incredibly un-PC). However, if you find something that presents similar evidence, I'm happy to take a gander and change my opinions.

From the evidence I've seen, that's not the case though.

 

[GeneralVeers]

If you have a study titled "Most Uninsured are Lazy Bastards" and it took a random sample of a couple thousand uninsured people and found that most of them just wanted to watch TV all day and eat Vicodin, then I will accept that as evidence of your beliefs. But that survey will be hard to find (because the title is incredibly un-PC). However, if you find something that presents similar evidence, I'm happy to take a gander and change my opinions.

From the evidence I've seen, that's not the case though.

The "lazy bastard" study would never get funding or be published. All studies into socioeconomic issues are conducted by people/institutions who are trying to present their own bias, and nudge public policy towards what they think it should become. Like the one that says 47 million AMERICANS are uninsured which every politician keeps quoting. When you boil down the sub-groups in there, the number is not nearly so large.

 

[EM2BE]

I have no doubt that you and GV both see many uninsured people with no inclination to work and every desire to leech off the system. I'm not arguing that fact at all.

But in statistics, that's called selection bias. You and GV take what you see and extrapolate to all uninsured people. What you don't consider is that your sample is not representative of all the uninsured. To get a true sample, it has to be a random selection of uninsured people.

And large surveys demonstrate that the majority of uninsured do in fact have jobs that earn them enough to put them above the poverty line but too little to buy health insurance (if they aren't perfect health and always have been).

So, you can tell me you see 8,000 uninsured people per day and they all come in for a Percocet refill, but I still won't use that experience to define the characteristics of the majority of uninsured people.

If you have a study titled "Most Uninsured are Lazy Bastards" and it took a random sample of a couple thousand uninsured people and found that most of them just wanted to watch TV all day and eat Vicodin, then I will accept that as evidence of your beliefs. But that survey will be hard to find (because the title is incredibly un-PC). However, if you find something that presents similar evidence, I'm happy to take a gander and change my opinions.

From the evidence I've seen, that's not the case though.

I am not working in an ED all the time. I am in clinics and hospitals. I still see this patient population though. Maybe it's that the more responsible ones only come in as a last resort and the others (not responsible) come in for more minor things because they aren't worried about paying their bills. I don't know. I'm just telling you that is what we see in the hospital (even admitted) and in the offices where I am. Not only that, but those that are leeching the system tend to also be the worst patients to work with. They are the ones sitting there with a note pad recording the names of people entering the room and what they say and then threatening to sue all the time. And like GV said, there will never be a study published on these factors because it looks bad for those who are trying to say otherwise and it will be "politically incorrect."

If the data published is correct, the patient population we see should reflect this. If there is 16% of the population uninsured, we should see that percentage in the hospitals/offices, but we don't. We see much more uninsured. Like I said, maybe it is the teaching hospital part that makes them come to these areas. Even if it were just a slightly higher percentage (20-30%) that showed up, I would be less likely to think they are leeching versus needing health care like everyone else.

Sorry if the above is a little scrambled...just woke up.

 

[leviathan]

True, due to the more MRI machines, more advanced treatments, and more prescription drugs in this country.

Can you provide proof of either of the latter 2 things? Obviously more MRIs are being done in the US, but for what purpose?

My question was concerning the sustainability of even the Canadian system. If you have a system whereby MORE THAN HALF of all your expenditures are on healthcare, it will lead to inevitable collapse of the system. In the U.S. we'd simply be replacing insane unsustainable expenditures using one system for insane, unsustainable expenditures in another system.

1. Yeah, you are right that either system seems to be unsustainable...but I don't think that means you have to maintain status quo.

2. As for the comments about life expectancy, you may be right that the US is a sicker country, but do you have any proof? When I drive the 10 minutes to cross the border into Washington state, I don't suddenly see a barrage of obese chain-smoking citizens hanging out waiting for their next big MI...at least not any more than what I see back home. Also, there is a big difference in death from preventable diseases...meaning when you compare a patient who already has coronary disease, they live much longer in Canada than in the US on average. Part of that has to do with the fact that nobody wants to see their doctor when it costs money to do so. Canada has a much higher rate of clinic visits per person. I agree that this can also be a bad thing (people abusing a 'free' system), but because our costs per capita are so much less than the US, there obviously isn't a problem with abuse.

3. Military spending: Canada is a small country population wise. When you have a country like the US which has 10x the population and 10x the spending power, that means we'd naturally have to put in 10 times more spending than the US does if we were going to be able to have the same military power. So what would your solution be to finding a way to defend a country of 30 million without wasting half of our entire budget on this process? Maybe I'm missing here, but it seems unreasonable to expect a small country to be able to 'defend' itself. If the US or any major country wanted to invade Canada, there's pretty much nothing we could do about it no matter what we invested, so why waste our money in the first place?

 

[RustedFox]

As for the comments about life expectancy, you may be right that the US is a sicker country, but do you have any proof? When I drive the 10 minutes to cross the border into Washington state, I don't suddenly see a barrage of obese chain-smoking citizens hanging out waiting for their next big MI...at least not any more than what I see back home.

Northern Washington has a remarkably similar sort of ethnic makeup/environmental factors/way of life to what you probably see up in BC. Come down to SoCal, or over to the East coast, and you'll be in for a shock. Where I'm at right now, I wouldn't mistake any of my ED patients for Canucks... largely because none of them speak anything that even closely resembles English... but the point is that 9/10 of my ED patients are the exact "train wreck" (HTN, DM, chain smoking, obese, etc...) that you described.

it seems unreasonable to expect a small country to be able to 'defend' itself. If the US or any major country wanted to invade Canada, there's pretty much nothing we could do about it no matter what we invested, so why waste our money in the first place?

I know of many smaller countries that constantly manage to fight off much larger adversaries. Take a good look at the middle east or southeast Asia. Not naming any names.

 

[GeneralVeers]

Leviathan, please join me down in South Texas the next time I go there. 80% of the population is obese, 30% have diabetes, and almost all have high blood pressure. It's a wonder people down there even make it into their 40's.

 

[Pharmavixen]

As for the comments about life expectancy, you may be right that the US is a sicker country, but do you have any proof? When I drive the 10 minutes to cross the border into Washington state, I don't suddenly see a barrage of obese chain-smoking citizens hanging out waiting for their next big MI...at least not any more than what I see back home. Also, there is a big difference in death from preventable diseases...meaning when you compare a patient who already has coronary disease, they live much longer in Canada than in the US on average. Part of that has to do with the fact that nobody wants to see their doctor when it costs money to do so. Canada has a much higher rate of clinic visits per person. I agree that this can also be a bad thing (people abusing a 'free' system), but because our costs per capita are so much less than the US, there obviously isn't a problem with abuse.

Hi, Leviathan. You're closer to the border than I am, in Toronto. Come summer we'll see the influx of American tourists. Um, not to be rude, but there will be all these really, really fat people from south of the border, who contrary to stereotype are quite nice and polite generally, but man, pushing maximum density.

Not that we're all whipcord thin up here in the socialist paradise; we have our share of the non-compliant T2 diabetics who eat their way into dialysis and bilateral amputations. But it is noticeably disproportionate.

Could single-payer health care make Americans thinner and healthier? (I can't see how, to be honest. Just tossing it out there as a talking point...)

 

[GeneralVeers]

Could single-payer health care make Americans thinner and healthier? (I can't see how, to be honest. Just tossing it out there as a talking point...)

The answer to that is no, unless the government starts rationing food as well......

 

[GoodmanBrown]

The answer to that is no, unless the government starts rationing food as well......

Isn't there some vague "proof" that ultra-low calorie diets extend lifespans? I think we're on to something here.

Not that I'm willing to give up my Twinkies, obviously.

 

[GeneralVeers]

Isn't there some vague "proof" that ultra-low calorie diets extend lifespans? I think we're on to something here.

Not that I'm willing to give up my Twinkies, obviously.

Yes, it's actually fairly well known. In experiments with mice they demonstrated an almost doubling of lifespan when fed near-starvation diets. I believe they demonstrated the concept in small primates too.

It's thought that when your caloric intake is low a "survival gene" kicks in and allows you to live long enough for food to become plentiful again.

I'd rather die early than eat a starvation diet for 50 years.....

 

[leviathan]

I know of many smaller countries that constantly manage to fight off much larger adversaries. Take a good look at the middle east or southeast Asia. Not naming any names.

If you are referring to certain middle eastern countries that were recently attacked by certain North American countries, then those countries were conquered years ago. They are fighting off with resistance forces, not overt military power in the sense of troops/tanks/etc. If the US decided to invade Canada, it doesn't matter how large our military was, you can't keep a country 10 times larger than you out. After they're in though, that doesn't mean you can't employ the same urban warfare that these other countires are using.
.

 

[leviathan]

The answer to that is no, unless the government starts rationing food as well......

Maybe not a bad idea.

On the subject of the health of Americans, I have been all over the US and never noticed any significant difference. However, it still doesn't remove the fact that our chronic disease management is much better here..the stats show a much longer life expectancy for people with CAD, DM, etc.

 

[GeneralVeers]

If you are referring to certain middle eastern countries that were recently attacked by certain North American countries, then those countries were conquered years ago. They are fighting off with resistance forces, not overt military power in the sense of troops/tanks/etc. If the US decided to invade Canada, it doesn't matter how large our military was, you can't keep a country 10 times larger than you out. After they're in though, that doesn't mean you can't employ the same urban warfare that these other countires are using.
.

Maybe we need to invade Canada in order to put an end to this socialized medicine menace for good!

 

[leviathan]

Maybe we need to invade Canada in order to put an end to this socialized medicine menace for good!

I'd pay for front-row seats to that invasion. I wonder how long it would take?

In all fairness, I heard a statistic that we had the 3rd largest military in the world back in WWII, when there was actually a legitimate reason for us to build up forces.

 

[GeneralVeers]

I'd pay for front-row seats to that invasion. I wonder how long it would take?

In all fairness, I heard a statistic that we had the 3rd largest military in the world back in WWII, when there was actually a legitimate reason for us to build up forces.

2nd largest Navy in the world too. It's a shame you're down to a fishing boat and a diesel submarine now.